To paraphrase the Bard, “that which we call a rose would, by any other name,” need to be double-checked to make sure it’s not a daffodil. Years ago, when I worked in a biochemistry department, we had a student in the lab who liked his coffee a little sweet. But rather than bring in his own sweetener or go down to the cafeteria to get a sugar pack, he liked to go to the bulk chemicals shelf and grab a scoop of sucrose.

One day, the student followed his normal routine (after weeks of warnings from the rest of us) and was quite surprised to find that his coffee was anything but sweet. Unfortunately, rather than grab the large white sucrose bottle with the yellow label, he grabbed another large white bottle with a yellow label. Luckily, it was sodium chloride. From then on, he brought in his own sugar.

Pretty stupid fellow, eh?

Recently, I spent some time looking over an issue of the Institute for Safe Medication Practices’ Medication Safety Alert and was concerned to read a short item about an automated pharmaceutical dispensing cabinet that was doling out 50 mg/mL ketamine instead of 10 mg/mL because the source company was experiencing a drug shortage.

Although everyone had been informed about the shortage, a nurse anesthetist prepared two syringes of the medication but only diluted one of them, causing problems with a patient. The hospital was lucky that other than some unexpected delirium and confusion, the patient was not seriously harmed by the mistake, but it does highlight an ever-present concern: dosing errors.

Unfortunately, a quick survey of clinicians and pharmacists suggests that this is a problem that is growing, and while I can’t speak to this specific case, a big part of this problem seems to stem from drug companies providing very similar packaging for different doses of the same drug. If dosing errors were only occurring in high-traffic sudden-action scenarios, we could quickly point the blame at the drug companies, but inappropriate dosing is also a problem in lower traffic departments.

Aside from the inherent desire to “do no harm”, the extremely litigious era in which we work these days makes it critical for medical practitioners and support workers to spend that extra time, to go that extra step to ensure that the chemicals they put into or onto patients’ bodies are appropriate.

At every turn, everyone in the healthcare process has to fight complacency to avoid these mistakes. If it means a checklist, if it means doubling up on signatures for each treatment, then that’s what we have to do.

The life you save may be your patient’s and the conscience (and possibly career) you save may be your own.